patient flow woe and the too few nurse curse

© 2005, Dimensional Insight, Inc.

Patient Flow Woe

and

The Too Few Nurse CurseJeff Ward,

Lee Memorial Health System

See us at

Booth# 6741


Agenda

• Why?

• Why Me!

• Patient Flow: From Woe to Woo-Hoo

• Too Few Nurse Curse: From Few to Phew

• The Next Step of the Journey

• Q&A


Why?

• Lee Memorial Health System

– A Not-For-Profit Corporation in Southwest

Florida.

– Comprised of 3 Acute Care Hospitals and

Multiple Other Facilities

– More than 6,200 Employees


Why?

• 3 Unique Demographic Challenges

– One of the Fastest Growing Metros*

– Way Too Much Sunshine!(Population Almost Doubles during Winter Months)

– Increasing Fraction Dependent on

Medicare, Medicaid and Charity Care

* Forecast magazine lists Fort Myers-Cape Coral 15th in its "Booming 25" ranking of the 25 fastest growing metro areas through the year 2005.


Why Me!

• In Healthcare IT Since 1985

• 14 Years at Lee Memorial

• Oversight of Business

Applications

• Helped Get Our Data Out of

Jail…


Patient Flow Woe

• A Busier ED, and yet…

• Good Data is the Key

• Insights Lead to Opportunities

• Opportunities Come in All Sizes…

– The $3m Opportunity




Volume

Continues

to Grow…ED Patient Volume (2004)

2000

2500

3000

3500

4000

4500

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEP

TEM

BER

OCTO

BER

NO

VEM

BER

DECEM

BER

Lee Memorial Hospital Cape Coral Hospital HealthPark Medical Center


But ED Becomes

the Doctor’s

Office! ED Admits as Percentage of ED Volume

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

22.0%

24.0%

26.0%

JANUARY

FEBRUARY

MARCH

APR

ILM

AY

JUNE

JULY

AUG

UST

SEP

TEM

BER

OCTO

BER

NOVEM

BER

DEC

EM

BER


Admit Rate is 80th Percentile*

* The Advisory Board, 2003 Data


…and Market

Share

Falls

67.165.1

63.0

57.9 57.154.9

ED Pediatric ED

Lee Memorial Health System ED Market Share (%)

2002 2003 2004


ED Patient Flow

Goals

• Length of Stay 15-25%

• Patients that Leave Without

Treatment 20%

• “Arrival” to “Seen by Physician” Time 15%

• Time from “Decision to Admit” to

“Inpatient Bed” 20%

• Wasted ED Bed Capacity 15%

• Utilization of Fast Track 30%

• Bed Turns 15%

• Productivity per Patient 15%

• Key Press Ganey Measures 83.5%

Decrease Increase


Fast Track is…

• Nurse Assesses whether to “Fast Track” Patient

– Eg. Patient Could Visit Doctor’s Office, or Condition is Not Life/Limb

Threatening

• Fast Track Patients Treated by Mid-Level Practitioner under

Direction of ED Physician

– RN & Technician Give Treatments, Discharge Instructions etc.

• When Fast Track is Closed, Fast Track Candidates

– Are Treated in Regular ED by ED Physician or Mid-Level

Practitioner

– Have Lower Priority

– May have Other Patients Pulled Ahead of them


Our Process

Improvement

Approach

• Drive Process Improvement via Small

Cycles of Change– Try Something for a Shift, a Day, a Week…

– Measure the Impact

– Tweak, Rollout, or Re-Think as Appropriate

• Previously used this approach to– Cut ED Divert from 500 Hours a Month to Zero

– Cut ED-to-IP Bed Turnaround Time by 10 Hours

– Improve ED Triage Time by 3 Hours


Initial Focus:

ED Waiting

Room

Fill-Out

Pre-Reg

Slip

Pre-Reg Triage

Range 3-13 Min. Range

2-90 Min.

Range 3–140 Min.Range

4-34 Min.

Waiting Waiting for

Transfer to Back

Average

2 Min.

+/- 3 Min. Average

27 Min.

Average

11.5 Min.

Average

39 Min.


A Real Patient

Flow Example

• Initially, Open Beds in ED

• Patient Fills Out “White Slip” Prior to Registration

• No-One at Registration Desk…

– Patient Waits 8 Minutes before being Registered

• Waited 2 Minutes for Triage Nurse

– Triage took 14 minutes

• Patient went back to Lobby via Wheelchair

– Now, 9 Open Beds in ED

• Patient Taken to ED Bed after 21 Minute Wait

43 Minutes Total to ED Bed


The Opportunity :

LWOTS

ED Visitors Leaving Without Treatment (%)

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

Janua

ry

Febru

ary

Mar

ch

Apr

il

May

June

July

Aug

ust

Sep

tem

ber

Oct

ober

Nov

ember

Dec

ember


National Average LWOTS = 2.5%1

1 The Advisory Board, 2003 Data


The Opportunity :

$3m

ED Patients Leaving Without Treatment: 6492

Average ED Charge($): $225

Lost ED Revenue: $1.5m

Lost Admits (5% of LWOTS): 324

Average Revenue for ED Admit($): $6265

Lost IP Revenue: $2.0m

Total Revenue Opportunity: $3.5m


Good Data is

The Key

7.3% 8.2%

30.4%

Lee Memorial Hospital Cape Coral Hospital HealthPark Medical

Center

Missing Dispositions


Congestion

Builds

During

The

Day

Time to Disposition (Mins.)

0

50

100

150

200

250

300

350

400

Patients Ordered by Time to RoomEarly AM Late PM

Moving Average Disposition Time


Mirrored by

ED Length

of Stay

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

1 AM

- 5

AM

7 AM

- 9

AM

9 AM

- 11

AM

11 A

M -

1 PM

2 PM

- 4

PM

4 PM

- 6

PM

6 PM

- 8

PM

10 P

M -

12 A

M

ED Length of Stay by Arrival Time (Hours)


The Opportunity :

Wasted Bed

Hours

9070

4759

23736

0

5000

10000

15000

20000

25000

Lee Memorial Hospital Cape Coral Hospital HealthPark Medical

Center

Wasted Bed Hours*

* Total Holding Time, Less 1 Hour per Patient

7.8% of System-wide Bed Hours

Are Holding Admits (Past 1 Hour)


The Opportunity :

$1m…

Wasted Bed Hours per Month: 1333

Assume 75% Probability to Pull Patient: 1000

Bed Turnover per Hour: 0.1

No. of Potential Patients 100

Average ED Charge($): $225

Cost of ED Holds $22,500

Repeat with Real Data, 3 Hospitals x 12 Months…

Total Revenue Opportunity: $1.2m

Using Dummy Data to Keep the Math Easy…


The Opportunity:

$12m

0.00

1.98

4.12

6.47

9.03

11.85

0 4 8 12 16 20

ED Length of Stay Reduction (%)

Length of Stay: Additional Revenue Potential ($m)

Based on: Lee Memorial Health System LOS = 300 Min.

National Average LOS* = 147 Min.

Best Practice LOS* = 91 Min.

National Average ED Revenue/Visit* = $ 225

National Average Revenue via ED Admission* = $6,778

* The Advisory Board, 2003 Data


Too Few Nurse

Curse

• Dealing With Industry-wide Skills

Shortage

– Become a Preferred Employer

– Focus on Nursing Productivity

– Data-Driven Retention & Recruitment

• Opportunities Come in All Sizes…


A Preferred

Employer

• Premier Workplaces: One of Ten “Premier Employers in Healthcare”1

– “Best in Class" for Outstanding People Practices and HR Programs that Attract and Retain Diverse Talent

– Reviewed Categories such as Compensation, Benefits, Diversity Strategies, Learning and Development, Work/Life Balance, and Culture and Values

• Herman Group: One of Four “Employer of Choice” Awards in Healthcare2

– “Employers of Choice, such as Lee Memorial Health System, who are able to attract, optimize, and retain top talent, will enjoy a substantial tactical advantage over their competitors”

-- Roger Herman, CEO of Employer of Choice, Inc.

1 Premier Workplaces, a national, independent, benchmarking organization, 20052 Herman Group, 2003


Making Timely

Staffing

Decisions

• Staffing & ADT Info is Automatically Integrated in “near Real-Time”

• Dynamic Decision Making on Nursing Skills Needed to Care for Current Patient Census

• Eliminate “Un-necessary” Overtime and Travelers thru Better, More Timely Decisions


Improving

Retention and

Recruiting

• Retained Additional 200 Staff

• $42k to Replace Nurse1

$8.4m Saved

20%

14%

Staff Employed Less Than 90 Days

1998 2003

53%

65%

Staff Remaining Employed After 1 Year

1998 20021 Estimated cost of replacing medical/surgical nurse,

Advisory Board Company for Nursing Executive Center, 2000.


Improving

Retention and

Recruiting

• Track

– KIWI (Key Information & Workforce Indicators) trends including turnover, hiring, terminations.

– Track JCAHO Compliance for HR data

• Easily Segregate Employee Population by Age, Length of Service, Direct Patient Care, VP etc.

– Eg. Average Age is 44.5 and Length of Service is 6.11 Years

7.8%

6.8%

Voluntary Staff Turnover

2003 2004


Q&A

See us at

Booth# 6741

patient flow woe and the too few nurse curse

Data & Analytics

dimensional insight

cut ed

regular ed

busier ed

ed bed capacity

ed triage time

ed patient flowgoals

percentage of ed volume10